NEW PATIENT FORMS
The following are some of my patient forms. In order to expedite our first sessions, they are available below to download as PDF documents. Please download, print, fill out and sign #1, #2 and #3. Bring the forms to our first session. Alternatively, if you wish, you may arrive 15-20 minutes early and I will have them on a clipboard in the waiting room for you to begin filling out.
- Informed Consent and Payment Agreement - Legally, I must disclose and you must read, understand and agree to these points before we can enter a therapeutic agreement. This is an abbreviated form of the Outpatient Services Agreement.
- Outpatient Services Agreement - In this document, I explain therapy and my office procedures. If you have any questions, I will be more than happy to use part of our first session to discuss these policies with you. On the last page are two places for your signature. The first is to acknowledge that I have handed you a copy of HIPAA (Health Insurance Portability and Accountability Act), which went into effect in April 2003. You may wait to sign until that time. The second acknowledges that you have read and I have offered to discuss the agreement.
- Confidential Client Information Questionnaire - This form will save time in the first few sessions as I get to know you and your history. I will read it between our first and second sessions and ask you to fill in information that may be relevant to your current concerns.
- Michigan Health Insurance Portability and Accountability Act - This is the Michigan law that went into effect on April 14, 2003. You have it here to reference.
To view and print the above documents, you will need Adobe Reader. Adobe Reader is available for download directly from the Adobe website.
